Cyclospora Attorney

Food Safety News reports that Texas officials are investigating an increasing number of Cyclospora parasite infections, asking for help from health care providers and warning the public that fresh produce is the possible source.

As of Thursday, 72 cases had been confirmed in the state, said Press Officer Christine Mann. That’s up from the 55 cases reported Monday in a health advisory from the state health department.

“Within the past month, 55 cases of Cyclospora infection have been reported to the Texas Department of State Health Services,” according to the advisory from state Health Commissioner Dr. John Hellerstedt.

“Rapid reporting to public health, enabling prompt investigation to identify possible common exposures, is essential to preventing additional cases of cyclosporiasis this year.”

State officials are recommending a series of lab tests for everyone who has symptoms of Cyclospora infection.

“Diagnosis of cyclosporiasis requires submission of stool specimens for ‘Ova and Parasite’ testing with additional specific orders for Cyclospora identification. A single negative stool specimen does not exclude the diagnosis; three specimens are optimal,” according to the advisory.

Symptoms usually begin two days to two weeks after ingestion of Cyclospora oocysts in contaminated food or water. Profuse diarrhea can last weeks to months and may relapse. Additional symptoms may include anorexia, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and low-grade fever.

As of August 21, 2015, CDC had been notified of 495 ill persons with confirmed Cyclospora infection from 30 states in 2015.

Most of these persons—293 (59%) of 495—experienced onset of illness on or after May 1, 2015, and did not have a history of international travel within 2 weeks before illness onset. These 293 persons were from the following 23 states: Arkansas (3), California (2), Connecticut (3), Florida (10), Georgia (23), Illinois (8), Iowa (1), Kansas (2), Maryland (1), Massachusetts (10), Michigan (2), Missouri (1), Montana (3), Nebraska (1), New Jersey (6), New Mexico (2), New York (excluding NYC) (9), New York City (21), North Carolina (1), Texas (168), Utah (1), Virginia (3), Washington (2), and Wisconsin (10).

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia.

Cluster investigations are ongoing in Texas and Georgia.

Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle.

Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert.

As of August 10, 2015 (3pm EDT), CDC had been notified of 457 ill persons with confirmed Cyclospora infection from 29 states in 2015. Most of these persons—275 (60%) of 457—experienced onset of illness on or after May 1, 2015, and did not have a history of international travel within 2 weeks before illness onset. These 275 persons were from the following 22 states: Arkansas (2), California (2), Connecticut (3), Florida (11), Georgia (22), Illinois (6), Iowa (1), Kansas (2), Maryland (1), Massachusetts (9), Michigan (2), Missouri (1), Montana (3), Nebraska (1), New Jersey (6), New Mexico (1), New York (excluding NYC) (8), New York City (21), Texas (157), Utah (1), Virginia (3), Washington (2), and Wisconsin (10).

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia.

Cluster investigations are ongoing in Texas and Georgia.

Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle.

Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert.

Public health officials are warning about an outbreak of the intestinal illness Cyclospora, with 83 cases are being investigated across Canada. The Public Health Agency of Canada has issued a statement that says two people have been hospitalized from the parasite but no deaths have been reported. The cases became known between May 9 and July 18 and are mainly in Ontario, but there are also some infections in B.C., Alberta and Quebec.

As of July 30, 2015, the CDC had been notified of 358 ill persons with confirmed Cyclospora infection from 26 states in 2015.

Most (199; 56%) ill persons experienced onset of illness on or after May 1, 2015 and did not report international travel prior to symptom onset.

Clusters of illness linked to restaurants or events have been identified in Texas, Wisconsin, and Georgia. Cluster investigations are ongoing in Texas and Georgia.

Cluster investigations in Wisconsin and Texas have preliminarily identified cilantro as a suspect vehicle. Investigations are ongoing to identify specific food item(s) linked to the cases that are not part of the identified clusters.

Previous U.S. outbreaks of cyclosporiasis have been linked to imported fresh produce, including cilantro from the Puebla region of Mexico. Read the related FDA Import Alert issued July 27, 2015.

FDA Investigators found:

Human feces and toilet paper found in growing fields and around facilities; Inadequately maintained and supplied toilet and hand washing facilities (no soap, no toilet paper, no running water, no paper towels) or a complete lack of toilet and hand washing facilities;

Food-contact surfaces (such as plastic crates used to transport cilantro or tables where cilantro was cut and bundled) visibly dirty and not washed;

Water used for purposes such as washing cilantro vulnerable to contamination from sewage/septic systems;

In addition, at one such firm, water in a holding tank used to provide water to employees to wash their hands at the bathrooms was found to be positive for Cyclospora cayetanensis.

Cyclospora is a parasite composed of one cell, too small to be seen without a microscope. The organism was previously thought to be a blue-green alga or a large form of Cryptosporidium. Cyclospora cayetanensis is the only species of this organism found in humans. The first known human cases of illness caused by Cyclospora infection (that is, cyclosporiasis) were first discovered in 1977. An increase in the number of cases being reported began in the mid-1980s, in part due to the availability of better diagnostic techniques. Over 15,000 cases are estimated to occur each year in the United States. The first outbreak in North America occurred in 1990 from contaminated water. Since then, several outbreaks of cyclosporiasis have been reported in the U.S. and Canada, many associated with eating fresh fruits or vegetables. In some developing countries, cyclosporiasis is common among the population and travelers to those areas have become infected as well.

Human feces and toilet paper found in growing fields and around facilities; Inadequately maintained and supplied toilet and hand washing facilities (no soap, no toilet paper, no running water, no paper towels) or a complete lack of toilet and hand washing facilities;

Food-contact surfaces (such as plastic crates used to transport cilantro or tables where cilantro was cut and bundled) visibly dirty and not washed;

Water used for purposes such as washing cilantro vulnerable to contamination from sewage/septic systems;

In addition, at one such firm, water in a holding tank used to provide water to employees to wash their hands at the bathrooms was found to be positive for Cyclospora cayetanensis.

The Centers for Disease Control and Prevention (CDC) and state public health officials have identified annually recurring outbreaks (in 2012, 2013, and 2014) of cyclosporiasis in the United States, which have been associated with fresh cilantro from the state of Puebla, Mexico. There is currently (in July 2015) another ongoing outbreak of cyclosporiasis in the United States in which both the Texas Department of State Health Services and the Wisconsin Department of Health Services and the Wisconsin Department of Agriculture, Trade and Consumer Protection have identified cilantro from the Mexican state of Puebla as a suspect vehicle with respect to separate illness clusters.

Texas DSHS has received reports of 205 Cyclosporiasis cases from around Texas this year, prompting an investigation into the infections in hopes of determining a common source. People who have a diarrheal illness lasting more than a few days or diarrhea accompanied by a severe loss of appetite or severe fatigue should contact their health care provider.

Past outbreaks have been associated with cilantro from the Puebla area of Mexico. While the investigation into the current outbreak is ongoing, imported cilantro has been identified as a possible source of some infections. The U.S. Food and Drug Administration recently issued an import alert detaining cilantro from that area coming into the U.S.

DSHS recommends thoroughly washing fresh produce, but that may not entirely eliminate the risk because Cyclospora can be difficult to wash off. Cooking will kill the parasite.

Cyclospora cayetanensis is a human-specific protozoan parasite that causes a prolonged and severe diarrheal illness known as cyclosporiasis. In order to become infectious, the organism requires a period outside of its host. Illnesses are known to be seasonal and the parasite is not known to be endemic to the United States. Cyclosporiasis occurs in many countries, but it seems to be most common in tropical and subtropical regions. People become infected with C. cayetanensis by ingesting sporulated oocysts, which are the infective form of the parasite. This most commonly occurs when food or water contaminated with feces is consumed. An infected person sheds unsporulated (immature, non-infective) C. cayetanenis oocysts in the feces.

As I said to ABC News:

Bill Marler, a Seattle-based food safety lawyer, said the number of cyclospora outbreaks in recent years is worrying.

“Banning the product is probably a bit past due given the numbers of outbreaks that have occurred, “said Marler. “The fact is that cyclospora is called an emerging pathogen. It’s relatively new bug making people sick in the U.S.”

A recent surge in reports of illnesses due to the parasite Cyclospora has prompted DSHS to investigate the infections in hopes of determining a common source. DSHS has received reports of 151 Cyclosporiasis cases from around Texas this year.

Cyclosporiasis is an intestinal illness caused by consuming food or water contaminated with the Cyclospora parasite. The major symptom is watery diarrhea lasting a few days to a few months. Additional symptoms may include loss of appetite, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and a low fever. People who think they may have a Cyclospora infection should contact their health care provider.

DSHS recommends thoroughly washing fresh produce, but that may not entirely eliminate the risk because Cyclospora can be difficult to wash off. Cooking will kill the parasite.

Last year, Texas had 200 cases, some of which were associated with cilantro from the Puebla region in Mexico.

What is cyclospora?

Cyclospora is a parasite composed of one cell, too small to be seen without a microscope. The organism was previously thought to be a blue-green alga or a large form of cryptosporidium. Cyclospora cayetanensis is the only species of this organism found in humans. The first known human cases of illness caused by cyclospora infection (that is, cyclosporiasis) were first discovered in 1977. An increase in the number of cases being reported began in the mid-1980s, in part due to the availability of better diagnostic techniques. Over 15,000 cases are estimated to occur in the United States each year. The first recorded cyclospora outbreak in North America occurred in 1990 and was linked to contaminated water. Since then, several cyclosporiasis outbreaks have been reported in the U.S. and Canada, many associated with eating fresh fruits or vegetables. In some developing countries, cyclosporiasis is common among the population and travelers to those areas have become infected as well.

Where does cyclospora come from?

Cyclospora is spread when people ingest water or food contaminated with infected stool. For example, exposure to contaminated water among farm workers may have been the original source of the parasite in raspberry-associated outbreaks in North America.

Cyclospora needs time (one to several weeks) after being passed in a bowel movement to become infectious. Therefore, it is unlikely that cyclospora is passed directly from one person to another. It is not known whether or not animals can be infected and pass infection to people.

What are the typical symptoms of Cyclospora infection?

Cyclospora infects the small intestine (bowel) and usually causes watery diarrhea, bloating, increased gas, stomach cramps, loss of appetite, nausea, low-grade fever, and fatigue. In some cases, vomiting, explosive diarrhea, muscle aches, and substantial weight loss can occur. Some people who are infected with cyclospora do not have any symptoms. Symptoms generally appear about a week after infection. If not treated, the illness may last from a few days up to six weeks. Symptoms may also recur one or more times. In addition, people who have previously been infected with cyclospora can become infected again.

What are the serious and long-term risks of cyclospora infection?

Cyclospora has been associated with a variety of chronic complications such as Guillain-Barre syndrome, reactive arthritis or Reiter’s syndrome, biliary disease, and acalculous cholecystitis. Since cyclospora infections tend to respond to the appropriate treatment, complications are more likely to occur in individuals who are not treated or not treated promptly. Extraintestinal infection also appears to occur more commonly in individuals with a compromised immune system.

How is cyclospora infection detected?

Your health care provider may ask you to submit stool specimen for analysis. Because testing for cyclospora infection can be difficult, you may be asked to submit several stool specimens over several days. Identification of this parasite in stool requires special laboratory tests that are not routinely done. Therefore, your health care provider should specifically request testing for cyclospora if it is suspected. Your health care provider might have your stool checked for other organisms that can cause similar symptoms.

How is cyclospora infection treated?

The recommended treatment for infection with cyclospora is a combination of two antibiotics, trimethoprim-sulfamethoxazole, also known as Bactrim, Septra, or Cotrim. People who have diarrhea should rest and drink plenty of fluids. No alternative drugs have been identified yet for people with cyclospora infection who are unable to take sulfa drugs. Some experimental studies, however, have suggested that ciprofloxacin or nitazoxanide may be effective, although to a lesser degree than trimethoprim-sulfamethoxazole. See your health care provider to discuss alternative treatment options.

How can Cyclospora infection be prevented?

Avoiding water or food that may be contaminated is advisable when traveling. Drinking bottled or boiled water and avoiding fresh ready-to-eat produce should help to reduce the risk of infection in regions with high rates of infection. Improving sanitary conditions in developing regions with poor environmental and economic conditions is likely to help to reduce exposure.

Washing fresh fruits and vegetables at home may help to remove some of the organisms, but cyclospora may remain on produce even after washing.

As of August 26, 2014, CDC has been notified of 133 cases of Cyclospora infection in Texas among Texas residents who did not travel outside the country within the two weeks prior to becoming ill. Four hospitalizations have been reported in Texas. Texas state health officials reported that most cases of the illness occurred in June and July 2014.

Epidemiological and traceback investigations have been conducted at four different restaurants in Texas, where multiple unrelated ill persons reportedly have eaten. All the ill persons in these four clusters reported having eaten a food item containing fresh cilantro in the 2-14 days before they became ill. Preliminary FDA and Texas state traceback investigation indicates that cilantro suppliers in Puebla, Mexico were a source of the cilantro that was served at the four restaurants.

Also as of August 26, 2014, the CDC had been notified of 304 ill persons with confirmed Cyclospora infection in 2014; of these, 207 ill persons from the following states had no history of international travel within two weeks before onset of illness: Arkansas, California, Connecticut, Florida, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Pennsylvania, New Jersey, New York (and New York City), Texas, Virginia, Wisconsin, and Washington.

Most (133; 64%) of the cases were reported from Texas.

Most (133; 64%) of the cases were reported in July 2014.

Most (176; 85%) of the illness onset dates occurred in June and July.

Among 183 persons with available information, 7 (4%) have reported being hospitalized. No deaths have been reported.

Among 204 persons with available information, ill persons range in age from 3 to 88 years, with a median age of 49 years.

Among 204 persons with available information, 115 (56%) of ill persons are female.

The Cyclospora illness outbreak being investigated by DSHS and local health departments in Texas along with the federal Centers for Disease Control and Prevention and Food and Drug Administration appears to have ended. The number of new illnesses being reported has returned to background levels, and the investigation has linked the cases in four restaurant clusters to cilantro imported from Puebla, Mexico.

Cyclosporiasis is an intestinal illness caused by consuming food or water contaminated with the Cyclospora parasite. The major symptom is watery diarrhea lasting a few days to a few months. Additional symptoms may include loss of appetite, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and a low fever. Symptoms may come and go multiple times over a period of weeks.

126 cases are considered part of the outbreak with an onset of illness after May 1 and no history of international travel within the two weeks before onset. Most cases occurred in June and July. However, it is unknown whether all illnesses are linked to cilantro. 166 total cyclosporiasis cases have been reported in Texas in 2014. Most of the cases are in residents of North Texas.

DSHS, in conjunction with local health departments, investigated four restaurant clusters in North Texas that included a total of 21 people who got ill. All 21 reported eating a food item from the restaurant containing cilantro within two weeks before becoming ill. A preliminary traceback investigation conducted by FDA and DSHS has identified Puebla, Mexico as the source of the cilantro that was served in all four restaurants. While the investigation has not found samples of cilantro contaminated with cyclospora, there is enough evidence to establish a strong epidemiological link between the illnesses and the cilantro. The state of Puebla was also identified as the source of fresh cilantro linked to a cyclosporiasis outbreak in 2013.

As of September 20, 2013 (5pm EDT), CDC has been notified of 643 ill persons with of Cyclospora infection from 25 states: Arkansas, California, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York (including New York City), Ohio, Pennsylvania, South Dakota, Tennessee, Texas, Virginia, Wisconsin, and Wyoming.
Most of the illness onset dates have ranged from mid-June through mid-July.

Public health officials in Iowa and Nebraska performed investigations within their states and concluded that restaurant-associated cases of cyclosporiasis in their states were linked to a salad mix produced by Taylor Farms de Mexico.

Epidemiologic and traceback investigations conducted in Texas by state and local public health and regulatory officials, the FDA, and CDC indicated that some illnesses among Texas residents were linked to fresh cilantro from Puebla, Mexico.

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About Bill Marler

Bill Marler is an accomplished personal injury and products liability attorney. He began litigating foodborne illness cases in 1993, when he represented Brianne Kiner, the most seriously injured survivor of the Jack in the Box E. coli O157:H7 outbreak.